17/8/2017 Bronchiolitis Treatment & Management: Approach Considerations, Initial Management, Admission Criteria

Bronchiolitis Treatment & Management

Updated: Jan 30, 2017
Author: Nizar F Maraqa, MD, FAAP; Chief Editor: Russell W Steele, MD more...

TREATMENT

Approach Considerations
Since no definitive antiviral therapy exists for most causes of bronchiolitis, management of these
infants should be directed toward symptomatic relief and maintenance of hydration and
oxygenation. Although numerous medications and interventions have been studied for the
treatment of bronchiolitis, at present, only oxygen appreciably improves the condition of young
children with bronchiolitis and many other medical therapies remain controversial. [7]

Bronchodilator therapy to relax bronchial smooth muscle, though commonly used, is not supported
as routine practice by convincing evidence. If bronchodilator therapy is started, it may be continued
in selected patients who demonstrate clinical improvement.

Despite the prominent role that inflammation plays in the pathogenesis of airway obstruction, large
multicenter trials of corticosteroids have clearly failed to show a significant benefit in improving the
clinical status of patients with bronchiolitis. [125] However, in some countries they are used
routinely.

Beta-agonists and ipratropium bromide, an aerosolized anticholinergic agent, have not shown
effectiveness in the management of infants with RSV and wheezing. [126, 127, 128, 129, 130]
Epinephrine trials have not shown benefit among outpatients with bronchiolitis or the hospitalized
child. Nasal phenylephrine is not effective for treatment of infants hospitalized for bronchiolitis. [131]

The efficacy of pharmacotherapy in infants is difficult to determine because it can be a function of

the pharmacologic agent, the route of administration, the clinical status of the patient, or the
adequacy of the outcome measure used to demonstrate an effect. Recombinant human DNAse
also had no clinical effects in infants who were not receiving ventilation. [132] Various
immunotherapies are being introduced both to treat the acute disease and to prevent sequelae.
[133, 134, 135, 136]

Guidelines for treatment

As a consequence of the lack of evidence-based support for medicinal interventions to treat
bronchiolitis, admission rates and treatment approaches vary widely, particularly in the emergency
department (ED). [137, 138] In a Canadian study, children evaluated in general EDs were admitted
twice as often as those observed in pediatric EDs, even when age, gender, estimated family
income, medical comorbidity, and clinical severity were controlled for. [139]

A survey of members of the Emergency Medicine section of the American Academy of Pediatrics
(AAP) found that 96% recommended bronchodilators and 8% recommended steroids. [3] Twice as
many pediatric emergency physicians would admit a child with an oxygen saturation of 92% on
pulse oximetry than would admit a child with a saturation of 94%, though a respiratory rate of 50
breaths/min as opposed to 65 breaths/min made little difference in the admission rate.

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A study of 30 large childrens hospitals in the United States found that 45% of patients received
steroids and 25% received systemic antibiotics. Factors that contributed to longer stays included
use of antibiotics, steroids, and bronchodilators. Undergoing chest radiography was a significant
predictor of antibiotic administration. [140]

These differences from recommendations and between practices have led to a call for national
guidelines for the management of bronchiolitis. In 2006, the AAP, in conjunction with the American
Academy of Family Physicians (AAFP), the American College of Chest Physicians (ACCP), and
the American Thoracic Society (ATS), published guidelines for the diagnosis and management of
bronchiolitis in children 1 through 23 months of age. [3] These guidelines were updated in 2014 and
include the following recommendations [110] :

Diagnosis and severity should be based on history and physical findings and not on
laboratory and radiologic findings; risk factors should be assessed when decisions about
evaluation and management are made
Bronchodilators should not be routinely used; routine use of a trial of bronchodilator therapy
was de-emphasized in the updated guidelines due to the lack of supportive evidence of
benefit exceeding potential harm
Corticosteroids should not routinely be used
Ribavirin should not be used
Risk of serious bacterial infection, especially in infants 30-90 days old with bronchiolitis is low.
Antibacterials should be used only upon proven coexistence of bacterial infection
Nutrition and hydration should be assessed. The ability of an infant with respiratory distress
due to bronchiolitis to take oral fluids should be evaluated and nasogastric or intravenous
hydration may be used as needed
Supplemental oxygen should not be routinely used for patients with saturations above 90%
on pulse oximetry; continuous pulse oximetry monitoring may not be necessary
Chest physiotherapy has not shown to benefit infants with bronchiolitis
Deep suctioning may provide temporary relief but has been associated with longer
hospitalization
Nebulized hypertonic (3%) saline may improve symptoms of bronchiolitis when length of stay
is expected to exceed 3 days
Palivizumab prophylaxis should only be administered to selected children (se below)
Hand decontamination is indicated to prevent nosocomial spread
Infants should not be exposed to passive smoking, and clinicians should inquire about
parental smoking and encourage cessation.
Breastfeeding is recommended
Clinicians should inquire about use of complementary and alternative medicine therapies

A recent report from the Value in Inpatient Pediatrics Network, formed out of the AAP section on
hospital medicine, found that using the AAP guidelines in a peer-to-peer collaborative manner
among the participating hospitals in 14 states reduced the use of bronchodilators to treat pediatric
bronchiolitis from 70% in 2007 to 58% in 2010. Bronchodilator doses per patient fell by 45% and
inappropriate use of chest physiotherapy also declined from 14% to 4.2% from 2007 to 2010 at the
participating hospitals. [141]

Researchers at Cincinnati Childrens Hospital found that bronchiolitis admissions were increasing
so that patients could receive bronchodilator therapy. In 1997, the hospital instituted evidence-
based point-of-care algorithms and rules based on guideline recommendations on the overuse of
therapies for bronchiolitis and reviewed them in 2001, 2005, and 2006.

The hospitals guidelines discouraged etiologic testing (because the treatment is directed at the
syndrome rather than at its cause), reduced the use of chest radiography (because opacities
[atelectasis] are unlikely to change for 7-9 days and are not influenced by antibiotics or chest
physiotherapy), and discouraged the use of steroids and bronchodilators unless clear and
sustained improvement was noted 20 minutes after aerosol administration. [142]

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After introduction of the guidelines, decreases were seen in admissions (29%), length of stay
(17%), nasopharyngeal washings for RSV antigen (52%), chest radiography (20%), all respiratory
therapies (30%), beta-agonist administrations (51%), cost of all services (37%), and cost of
respiratory therapy services (77%). [143] These changes continued in the 3-year and 4-year follow-
up investigations. [144]

Initial Management
Patients should be made as comfortable as possible (held in a parents arms or sitting in the
position of comfort). Administer saline nose drops and perform nasal and oral suctioning. Deep oral
and nasal suctioning is not routinely needed. Carefully monitor the patient for apnea. Pay attention
to temperature regulation in small infants. [8]

Cardiorespiratory monitoring is essential. Pulse oximetry is a helpful tool; hypoxia is common. It is

vital to have a clear picture of the patients clinical respiratory status and the severity of disease.
The ability to maintain adequate hydration should be assessed by observing the patient's oral
intake. Many dyspneic infants have difficulty taking a bottle.

Although young infants have the unique ability to breathe and swallow simultaneously, the risk of
aspiration is significant when the respiratory rate is higher than 60 breaths/min. Fever and
hyperpnea may contribute to excessive fluid losses. For these reasons, infants who are
hospitalized with bronchiolitis require careful fluid monitoring and provision of nasogastric or
intravenous (IV) fluids when hyperpnea precludes safe oral feeding.

An early effort should be made to isolate or cohort patients who are confirmed or likely to have
RSV infection, especially from other patients at risk for severe disease. Institute standard and
contact isolation precautions to prevent nosocomial transmission.

Antibiotics are not indicated unless bacterial infection is highly suspected (eg, by a toxic
appearance, hyperpyrexia, consolidation or focal lobar infiltrates on chest radiography,
leukocytosis, or positive bacterial cultures). [3] Concomitant otitis media is common and may be
treated with oral antibiotics.

Admission Criteria
A decision must be made as to whether the patient should be treated in an inpatient or an
outpatient setting. For hospitalized patients, the length of stay averages 2-3 days, with a
readmission rate of 1-4%. Considerations for hospital admission may include the following [38, 40,
145] :

Persistent resting oxygen saturation below 90% in room air

Markedly elevated respiratory rate (>70-80 breaths/min)
Dyspnea, intercostal retractions and cyanosis (indicating respiratory distress)
Chronic lung disease, especially if the patient is already receiving supplemental oxygen
Congenital heart disease, especially if hemodynamically significant (associated with cyanosis
or pulmonary hypertension)
Prematurity
Age younger than 3 months, when severe disease is most common
Inability to maintain oral hydration in patients younger than 6 months and difficulty feeding as
a consequence of respiratory distress
Parent unable to care for child at home

A decision must also be made regarding admission to an intensive care unit (ICU). Criteria for ICU
admission vary greatly. In general, ICU admission is uncommon for previously healthy infants who
present with bronchiolitis. Severely ill children should be admitted to an adequately equipped

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intensive care unit (ICU). If this requires transfer to another hospital, transport personnel and
vehicles specifically intended for pediatric transport are desirable.

Patients with the following conditions should be evaluated for ICU admission:

Worsening hypoxemia or hypercapnia

Worsening respiratory distress
Persistent oxygen desaturation and/or severe cyanosis in spite of adequate oxygen delivery
Apnea
Acidosis
Extrapulmonary symptoms
Worsening mental status
Unclear etiology of symptoms

Supportive Therapy
Management is primarily supportive and should focus on therapies that improve oxygenation and
hydration.

Oxygen supplementation
Administer supplemental humidified oxygen, if necessary, to maintain a transcutaneous oxygen
saturation higher than 90%. Unger and Cunningham found that oxygen supplementation is the
prime determinant of length of hospitalization. [7] The use of high-flow nasal cannulas may reduce
intubation rates in infants with bronchiolitis. [146]

In selected children with acute bronchiolitis, home oxygen therapy may be a feasible alternative to
traditional hospital oxygen therapy. In one study, 44 children aged 3-24 months who still required
oxygen supplementation 24 hours after admission were randomly assigned either to receive
oxygen therapy at home or to continue inpatient oxygen therapy. [147] Children in the home oxygen
group spent almost 2 days less in a hospital bed than those managed as traditional inpatients. No
difference in clinical outcome was noted.

Maintenance of hydration

Infants with bronchiolitis are mildly dehydrated because of decreased fluid intake and increased
fluid losses from fever and tachypnea. Accordingly, it is vital to maintain adequate hydration. The
goal of fluid therapy is to replace deficits and to provide maintenance requirements. Avoid
excessive fluid administration, because this may promote interstitial edema formation, particularly if
a component of inappropriate antidiuretic hormone release is present. [98]

Oral therapy is preferred. Parenteral therapy may be necessary in those patients who are unable to
take fluids by mouth or who have a respiratory rate higher than 70 breaths/min. Patients with
apneic episodes should have access to IV hydration.

Mechanical ventilation
Infants with bronchiolitis and recurrent apnea or increased work of breathing with respiratory failure
occasionally require mechanical ventilation. Treat these patients supportively, providing adequate
oxygen, ventilation, and hydration. Continuous positive airway pressure (CPAP) and intermittent
mandatory ventilation (IMV) with positive end-expiratory pressure (PEEP) have been successfully
used to treat these infants. [148, 149, 150, 151] Negative-pressure ventilation has been used
successfully in infants with bronchiolitis, with a reduced need for endotracheal intubation and
shortened lengths of stay.

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The typical approach in patients who require ventilation using IMV and PEEP is to ventilate at rates
slow enough to allow adequate emptying during exhalation. In addition, a short inspiratory time
optimizes ventilation to more compliant lung units without overdistending more obstructed ones.
Aggressive weaning over the first 2-3 days is not warranted and is usually unsuccessful. Once the
illness subsides, weaning can proceed quickly. Infants with progressive hypoxemia that does not
respond to conventional ventilation may respond to high-frequency ventilation or extracorporeal
membrane oxygenation (ECMO). [126, 152]

Several studies have looked into use of surfactant and nitric oxide in cases of severe respiratory
distress; however, the results were not sufficiently conclusive to support routine use in bronchiolitis.
[138, 153, 154] A meta-analysis of several small studies suggests that surfactant therapy may shorten

the duration of ICU stay in children undergoing ventilation for severe bronchiolitis. [155]

Heliox is a mixture of oxygen (20-30%) and helium (70-80%) that has lower viscosity than air. It
has been used successfully in cases of airway obstruction, croup, airway surgery, and asthma to
reduce respiratory effort during the period of airway compromise. Several studies have shown
improved respiratory distress scores in patients breathing heliox and have suggested that
combining heliox with nasal CPAP may render intubation unnecessary. [156, 157, 158, 159, 160, 161,
162]

Pharmacologic Therapy
Medications have a limited role in the management of bronchiolitis. Several drugs are commonly
used (eg, bronchodilators), but there is little in the way of conclusive evidence to support routine
use of any drug in the management of bronchiolitis.

In patients who are febrile, have bronchiolitis, and are at high risk, including those who have
nosocomial RSV infection or who appear toxic at presentation, the risk of secondary bacterial
infection is increased but remains small. The decision to start antibiotics should be made on a
case-by-case basis.

Bronchodilators
Although the use of bronchodilators in patients with bronchiolitis remains widespread, the data are
insufficient to support this approach as routine practice. One practical approach is to continue the
use of bronchodilators only in patients who demonstrate clinical improvement after initial use of
these agents.

A meta-analysis reviewed 15 randomized placebo-controlled trials of inhaled albuterol treatment in

bronchiolitis. [126] It concluded that albuterol produces only modest short-term improvement in
clinical features of mild or moderately severe bronchiolitis, primarily by making the child more alert.

A meta-analysis of 9 clinical trials noted that conclusive evidence of the efficacy of beta2 -agonist
therapy for bronchiolitis is unavailable and that routine use of such therapy for bronchiolitis is
unsupported. [127] A 2000 Cochrane review of the use of bronchodilators for bronchiolitis further
confirmed the lack of direct evidence of a sustained benefit. [163] A 2010 Cochrane review found
that bronchodilators do not improve oxygen saturation, shorten hospital stay, decrease the need for
hospitalization, or reduce the length of illness at home. [164]

One study compared nebulized albuterol with normal saline in an age-matched and severity-
matched trial of 52 infants over 72 hours of treatment. [128] Nebulized albuterol did not improve
recovery or attenuate severity, as indicated by improvement in oxygen saturation, length of stay, or
clinical score.

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Two randomized studies evaluating albuterol, ipratropium, and both medications combined against
normal saline found no improvement with medications. [129, 165] In a prospective, nonrandomized
study, inhaled albuterol did not yield a significant improvement in the respiratory status of infants
with RSV-induced respiratory failure, regardless of whether they had an obstructive or restrictive
pulmonary dysfunction. [166]

Only a single nonrandomized study of 25 ventilated young infants (13 of whom were premature or
had preexisting cardiopulmonary disease) with RSV bronchiolitis demonstrated a statistically
significant increase in maximum volume functional residual capacity (Vmax FRC) with aerosolized
albuterol; however, in 3 of these infants, respiratory function worsened. [167]

Although initial evidence suggested that nebulized racemic epinephrine reduced symptoms and
length of hospital stay, [168, 169, 170] subsequent studies did not support the use of epinephrine. [171,
172, 173]

A randomized, double-blind, placebo-controlled study of 62 somewhat older children (age, 6 weeks

to 2 years; mean age, 6.4 months) compared aerosolized racemic epinephrine with albuterol.
Racemic epinephrine resulted in significant improvement in wheezing and respiratory distress
score on day 2 but did not shorten hospitalization or total duration of illness. [168]

However, in a randomized placebo-controlled trial of albuterol and epinephrine in equipotent doses,

neither drug reduced the need for oxygen or reduced length of stay. [174] Moreover, neither drug
reduced the quantity of oxygen required or reduced clinical respiratory scores. [174, 175]

In an editorial, Wohl and Chernick, both highly respected experts on bronchiolitis, speculated that
inhaled epinephrine may relieve symptoms by acting as a nasal decongestant and that similar
nose drops may help to relieve symptoms [176] ; a follow-up letter to the editor asked for a
controlled study to end the speculation.

In a systematic review and meta-analysis of the use of steroids and bronchodilators for acute
bronchiolitis in the first 2 years of life, Harling et al found the majority (83%) of the 48 studies
reviewed to have either high or unclear bias. [177] The evidence only shows effectiveness and
superiority of epinephrine for most clinically relevant outcomes among outpatients with acute
bronchiolitis.

This conclusion is largely based on a multicenter, double-blind, placebo-controlled trial that

randomized 800 infants (age, 6 weeks to 12 months) to 1 of 4 treatment arms (nebulized
epinephrine plus oral dexamethasone, nebulized epinephrine plus oral placebo, nebulized placebo
plus oral dexamethasone, and nebulized placebo plus oral placebo). [178] In this large trial, the
combination of nebulized epinephrine and oral dexamethasone may reduce the risk of admission
within 7 days of a visit to the ED.

In a double-blind study, Livni et al found no significant differences between inhaled epinephrine

and nasal decongestant in hospitalized infants with acute bronchiolitis in terms of length of
hospitalization, need for oxygen supplementation, or IV fluids and clinical score. They concluded
that nasal decongestant is as effective as inhaled epinephrine for treatment of acute bronchiolitis.
[179]

Multiple authors have recommended instillation of saline nose drops before feeding. Instillation of
the lowest concentration of nasal decongestant drops 2-3 times a day for no more than 3 days in
hospitalized infants could be evaluated for its benefits.

Because bronchodilators lack demonstrable efficacy in bronchiolitis, it may be reasonable to

administer a beta-agonist on a trial basis only to older patients with a personal or family history of
asthma and then to assess the clinical response in 10-15 minutes. If retractions, respiratory rate,
and wheezing improve, scheduled aerosol treatments may be continued, with additional treatments

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given as needed. If little or no sustained response is noted, bronchodilator therapy should cease,
because it contributes to agitation and ventilation-perfusion ratio mismatching.

Antivirals and antibiotics

Antiviral therapy is not routinely recommended for cases of bronchiolitis. Although ribavirin has the
potential to reduce days of mechanical ventilation and hospitalization, these effects have been
inconsistent and are insufficient to support its routine use to treat RSV infections, [3, 82, 180, 181, 182]
and the AAP recommends against such use. [110, 3] However, the AAP suggests that ribavirin
aerosol therapy may be considered in selected groups of infants and young children at high risk for
potentially life-threatening RSV disease:

Those with complicated congenital heart disease (including pulmonary hypertension) and
those with bronchopulmonary dysplasia, cystic fibrosis, and other chronic lung disease
Those with underlying immunosuppressive disease and those who are severely ill with or
without mechanical ventilation
Hospitalized patients who are younger than 6 weeks or who have underlying conditions (eg,
multiple congenital anomalies or certain neurologic metabolic diseases)

Placebo-controlled studies have not found ribavirin to be clinically effective in children with
bronchiolitis. Long-term follow-up studies of ribavirin have not consistently shown a beneficial
effect on pulmonary function. Furthermore, this therapy is very expensive. Use of aerosolized
ribavirin in mechanically ventilated patients requires administration by physicians and support staff
familiar with this mode of administration and the specific ventilator. Given the high cost and the lack
of proven benefit, ribavirin therapy is difficult to justify in this setting.

Viruses are the primary etiologic agents in bronchiolitis; therefore, routine administration of
antibiotics has not been shown to influence the course of this disease. In young, acutely ill infants,
excluding the presence of secondary bacterial infection on clinical grounds may be difficult. Thus,
administration of broad-spectrum antibiotics in such critically ill infants may be justified until
bacterial culture results prove negative. Studies have shown that the risk of concurrent serious
bacterial infections in nontoxic-appearing infants with bronchiolitis is low. [85, 86]

It should be kept in mind that a positive test result for RSV does not exclude coinfection with other
respiratory pathogens. Co-infection with parainfluenza, influenza, measles, adenovirus, hMPV,
pertussis, Legionella, and Pneumocystis are all possible. Severe cases and those that do not
follow typical courses for RSV bronchiolitis may benefit from investigation for co-infections.

Anti-inflammatory agents

The belief that corticosteroids can prevent or reduce the major pathology of inflammation and
edema of the bronchiolar mucosa is tempting. However, the data indicate that these agents should
not be used routinely in this setting. Numerous studies have failed to conclusively define a
beneficial role for routine use of glucocorticoids in the treatment of infants with bronchiolitis. [125,
183, 184, 185, 186, 187, 188, 189]

Additionally, a Cochrane Review that included 13 trials of 1198 children aged 0-30 months failed to
demonstrate improvements in length of stay, clinical score, hospital admission rates, or
readmission rates for either systemic or inhaled corticosteroids administered either in the hospital
or in the ED. [190] Nevertheless, Weinberger cited several small studies suggesting that high-dose
systemic steroids early in the course of bronchiolitis may be effective in preventing the progression
of inflammation or, at least, in modifying its course. [191]

Plint et al found that combining dexamethasone and epinephrine may reduce hospital admissions
for infants with bronchiolitis treated in the ED. [178] In this trial, 800 infants were assigned to 1 of 4
treatment groups (nebulized epinephrine and oral dexamethasone, nebulized epinephrine and oral
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placebo, nebulized placebo and oral dexamethasone, or nebulized placebo and oral placebo). Only
the infants in the epinephrine-dexamethasone group were significantly less likely to be admitted to
the hospital within 7 days of treatment.

Sumner et al, using data from the Canadian Bronchiolitis Epinephrine Steroid Trial, found
epinephrine and dexamethasone to be the most cost-effective treatment for bronchiolitis in infants
aged 6 weeks to 12 months. [192]

Corticosteroids may be useful in patients with history of reactive airway disease. Steroid treatment
has not been shown to decrease the long-term incidence of wheezing or asthma after RSV
infection. Nebulized steroid treatment has not been proven efficacious.

In a study by Croe et al, the mast cell inhibitor cromoglycate had no beneficial effects. [193] One
study suggested that montelukast, a Cys-LT receptor antagonist, may reduce postbronchiolitis
reactive airway disease, but this intervention cannot be recommended at this time. [194]

Hypertonic saline
While nebulized hypertonic saline have been used for treating hospitalized, as well as ambulatory,
children with viral bronchiolitis with varying degrees of success, there is accumulating convincing
evidence that does not support hypertonic saline's effect in reducing length of hospital stay for
acute viral bronchiolitis in a typical US population (where the length of stay is 2.4 days on
average). [195, 196, 197, 198]

In a prospective, double-blinded, multicenter trial, the use of nebulized 3% hypertonic saline was a
safe, inexpensive, and effective treatment for moderately ill hospitalized infants with viral
bronchiolitis. [199] In a randomized, double-blind trial of 187 infants younger than 18 months with
acute bronchiolitis, Al-Ansari et al found that nebulization with 5% hypertonic saline was safe and
superior to 0.9% saline, and possibly superior to 3% hypertonic saline, for early ambulatory
treatment of bronchiolitis. [200] A multicenter trial with a larger sample size may help establish the
clinical benefits of this therapy.

Brooks et al reanalyzed the existing data on the benefit of nebulized hypertonic saline for infants.
The study concluded that prior analyses were driven by an outlier population and unbalanced
treatment groups in positive trials and that once heterogeneity was accounted for, the data did not
support the use of hypertonic saline to decrease hospital length of stay in infants hospitalized with
bronchiolitis. [197, 198]

Chest Physiotherapy
Medical therapy for bronchiolitis seems to be disappointing, but chest physiotherapy cannot be
recommended either. In 3 clinical trials of unventilated hospitalized infants that compared vibration
and percussion techniques in postural drainage positions with no intervention, no differences were
reported with respect to length of hospital stay, oxygen requirements, or severity of clinical score in
infants with bronchiolitis. [201]

A 2012 Cochrane review, which included 9 studies of children younger than 2 years with acute
bronchiolitis, confirmed that chest physiotherapy does not decrease the severity of the disease,
improve respiratory parameters, shorten the hospital stay, or reduce oxygen requirements in
nonventilated hospitalized patients. Various chest physiotherapy modalities (vibration and
percussion or forced expiratory techniques) have shown equally negative results. [202]

Complications of Therapy
Complications of therapy include the following:
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Ventilator-induced barotrauma
Nosocomial infection
Beta-agonistinduced arrhythmias
Nutritional and metabolic abnormalities

Strict attention to fluid and nutritional therapy, avoidance of unnecessary invasive monitoring,
infection control, and judicious ventilator management (including the use of high-frequency
oscillatory ventilation to avoid volutrauma, barotrauma, or both), may preclude many of these
complications.

Discharge Criteria
Once the relevant criteria are met, the patient may be discharged. Specific discharge criteria for
bronchiolitis patients vary considerably from one institution to another, as reported by Weiss and
Annamalai. [203] The fundamental considerations in formulating such criteria are as follows [203, 204]
:

The ability of the caretaker to manage the infants nasal congestion

Improvement in respiratory distress, as evidenced by a respiratory rate lower than 60-70
breaths/min and a resting oxygen saturation above 90% without supplemental oxygen
Adequate oral intake
The education and confidence of the caretaker

Various criteria for discharge have been proposed, including the following:

Clinical improvement
Oral intake adequate to maintain hydration status
Age older than 2 months without a history of prematurity
No apnea in the preceding 24 hours (in infants younger than 6 months) or the preceding 48
hours (in patients older than 6 months)
Acceptable oxygen saturation for more than 1 day, either on room air or on stable oxygen
therapy of less than 0.5 L/min via nasal cannula if discharged on home oxygen
Respiratory rate lower than 60-70 breaths/min
Minimal retractions at rest (not crying)
No underlying cardiopulmonary disease
When appropriate, home oxygen therapy arranged and parents educated in its use
Reliable caregivers with transportation available
Follow-up arranged with primary care physician

For patients who are hospitalized, a follow-up appointment with a primary care physician 1-2 days
after discharge is indicated to recheck room air saturation and to reassure parents. No further
laboratory testing is necessary unless the patient must test RSV-negative for return to an
environment where high-risk patients are present (eg, a medical childcare center or group home). It
may be important to note that secretions may remain positive for RSV for as long as 21 days after
the onset of symptoms. [22]

Children who required inpatient antibiotics for concurrent bacterial infection should continue to
receive the same antibiotics so as to complete the prescribed course. An older child with reactive
airway disease may require continued treatment with bronchodilators.

When discharging infants younger than 2 months, keep in mind that prior hospitalization and male
gender may predispose these patients to unscheduled return visits to the ED. Provision of targeted
discharge information and arrangement of follow-up care with a primary care physician would be
particularly helpful for this group of infants. [205]

Prevention
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RSV is transmitted via direct contact with secretions of infected patients. Droplets and fomites play
a less important role. Meticulous attention to handwashing between patient contacts should reduce
the likelihood of hospital staff acquiring RSV infection from patients and of spreading infection by
carrying RSV on their hands. [60, 61, 206, 207, 208]

Attempts to develop a safe and effective RSV vaccine have thus far been unsuccessful. A 1967
study of a formalin-inactivated RSV vaccine resulted in a 15-fold increase in hospitalization and
mortality when immunized patients were subsequently reinfected; an adequate explanation for this
exaggerated pulmonary response has not been elucidated. [209] Efforts to develop an RSV vaccine
continue. [210] A live-attenuated intranasally administered RSV vaccine is being developed. Another
approach being studied involves maternal immunization against RSV during pregnancy, with the
hope of providing neutralizing antibodies that cross the placenta to protect the infant. [211]

Active prophylaxis using RSV immunoglobulin intravenously (RSV-IGIV) at high doses was shown
to prevent RSV in high-risk patients. [212] However, a more convenient RSV-specific humanized
mouse IgG1 monoclonal antibody preparation, palivizumab, was subsequently developed and
FDA-approved in 1998 for prophylaxis for infants at high risk for RSV infection. Palivizumab is
administered intramuscularly (IM) at a dose of 15 mg/kg every month for a maximum of 5 doses
during the RSV season (ie, from October through February in most U.S. regions). [213]

In a multi-institutional, randomized, placebo-controlled study of 1502 high-risk preterm infants in

139 centers in the United States and Canada during the 1996-1997 RSV season, rate of
hospitalization was reduced by 5.8% (10.6% in placebo vs. 4.8% in palivizumab group, P<0.001).
[214] Infants receiving palivizumab had reduced hospital length of stay, days on oxygen, and ICU
admissions. Adverse effects were uncommon. Romero summarized 4 outcome studies
encompassing over 16,000 children after the use of palivizumab; all showed high effectiveness in
reducing RSV admissions. [215]

A 2005 study of PICU admissions for bronchiolitis did not demonstrate a decrease in admissions or
need for ventilation before and after palivizumab was licensed. In this study, 83% of the infants
admitted to the ICU did not meet AAP criteria for RSV prophylaxis. [216] Stevens and Hall
summarized the controversies regarding the use of palivizumab for children born at 32-35 weeks
gestation. They concluding that if these infants do not have chronic lung disease and are younger
than 6 months at the start of the RSV season, they may benefit from RSV prophylaxis if at least 2
of the following are observed: daycare attendance, school-aged siblings, passive smoke exposure,
airway abnormalities or neuromuscular disease. [217]

Since palivizumab was licensed for RSV immunoprophylaxis, the recommendations for its use
have become more restrictive as additional information became available regarding the
epidemiology of RSV hospitalizations and the limited benefit of prophylaxis in selected patient
populations. AAP guidance regarding palivizumab use [213] is stratified according to risk and can be
summarized as follows:

Preterm infants born before 29 weeks of gestation, without chronic lung disease of
prematurity or congenital heart disease and less than 12 months of age at the start of RSV
season; those born on or after 29 weeks of gestation should NOT receive prophylaxis as their
rate of hospitalization for bronchiolitis is not different from full0term infants.
Preterm infants born before completing 32 weeks of gestation with chronic lung disease of
prematurity and requirement for supplemental oxygen for the first 28 days of life.
Infants born with acyanotic congenital heart disease. Palivizumab is NOT recommended
routinely for infants with cyanotic congenital heart diseases there is no significant reduction in
rate of hospitalization for RSV.
For children older than 12 months of age, palivizumab is recommended only for when there is
chronic lung disease requiring supplemental oxygen or diuretic or glucocorticoid therapy.

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Prevention of serious RSV infection by giving palivizumab may reduce the incidence of subsequent
wheezing. [218, 219]

Unfortunately, although the use of palivizumab is possibly cost-effective, the cost per individual
patient is still high (approximately $5000), which means that the availability of this agent is limited
to high-risk patients. [4, 220, 221]

In a randomized, double-blind, multinational, phase 3 noninferiority trial comparing motavizumab (a

monoclonal antibody with enhanced anti-RSV activity in preclinical studies) with palivizumab,
motavizumab recipients had a 26% relative reduction in RSV hospitalization. [222] This result
established that motavizumab was not inferior to palivizumab, but it did not meet the researchers
criteria for establishing superiority. The data also revealed that motavizumab significantly reduced
outpatient RSV-specific, medically attended lower respiratory tract infection. [222] Consequently, the
researchers concluded that motavizumab may offer an improved alternative for preventing serious
RSV disease in high-risk infants and children. [222] However, in 2010, the FDA voted against
licensing motavizumab due to concerns that it did not offer significant improvement and cause
higher adverse hypersensitivity skin reactions when compared to palivizumab.

Several studies have demonstrated a beneficial effect of breastfeeding, particularly prolonged

nursing, for preventing or lessening the severity of RSV bronchiolitis. [10, 11]

Consultations
When a healthy infant presents with a history, physical examination findings, and course consistent
with uncomplicated bronchiolitis, no consultations are necessary.

However, refer infants with comorbidities, atypical histories, or critical conditions should be referred
to a pediatrician, preferably at a center that can provide a spectrum of pediatric subspecialists in
critical care, pulmonology, and infectious diseases.

Long-Term Monitoring
Most previously healthy children with bronchiolitis recover with few complications, but the
resolution of symptoms may take weeks. Follow-up should be arranged with the primary care
physician.

Among those with severe disease, a few may develop respiratory failure and experience a
protracted hospital course. Some patients will require supplemental home oxygen therapy at the
time of discharge. On follow-up, these patients should be evaluated to document resolution of the
need for oxygen therapy. An association between RSV bronchiolitis and subsequent wheezing and
asthma has been noted, but proof of causality is lacking at present. Parental education is an
important part of discharge planning.

Electronic cardiac and respiratory monitoring is required for some patients (persons who are very
sick, are very young, or are having apneic episodes). This monitoring should be discontinued in a
timely manner when it is no longer necessary.

Bronchiectasis after bronchiolitis

Long-term pulmonary sequelae after RSV bronchiolitis are uncommon and may include
subsequent wheezing. However, with adenoviral infection, severe lung damage, bronchiectasis,
and hyperlucent lungs may result.

Bronchiectasis after bronchiolitis is uncommon but has been described, with many reports
implicating adenovirus. Adenovirus is a known cause of bronchiectasis after several childhood

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infections, especially adenovirus types 3, 7, and 21. Bronchiectasis has also been noted after
bronchiolitis in patients co-infected with RSV and adenovirus. In this setting, adenovirus is believed
to be the causative factor, given its propensity to cause bronchiectasis.

Long-term outcomes after infections with these pathogens may vary as a result of differences in
immune response. Higher levels of interferon gamma and soluble CD 25 and lower levels of
soluble tumor necrosis factor receptor II are observed with primary adenoviral infection in infants
than with RSV infection. An imbalance in the ratio of T helper cell type 1 (Th1) to Th2 has been
observed, favoring Th1 in adenoviral infections and Th2 in RSV infections. Symptoms and
treatment of bronchiectasis after bronchiolitis are similar to those in other settings.

Beta agonists, administered by inhaler or nebulizer, may be continued on an outpatient basis if the
child responds to them while in the ED. If inhalers are prescribed, a mask and spacer should be
provided and the patients caregiver instructed in their use before discharge.

Immunoglobulin deficiency and recurrent bronchiolitis

Recurrent respiratory infections, including bronchiolitis, have been reported in children with
immunoglobulin A (IgA) or immunoglobulin G (IgG) subclass deficiency. In a report of 225 children
aged 6 months to 6 years with recurrent sinopulmonary infections, the overall frequency of
antibody defects was 19.1%. [223] IgA or IgG subclass deficiency was found in 25% of patients with
recurrent upper respiratory tract infections, 22% of patients with recurrent pulmonary infections,
and 12.3% of patients with recurrent bronchiolitis.

Guidelines

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